In our internal audits, the auditor is counting the word "pain" as a Quality element in the HPI. In all the examples I've seen from various sources, including CMS and various E/M courses I've taken, I've never come across "pain" as a Quality. Throbbing or burning pain, yes, but just pain?
Recently she counted "palpitations" and "infection" as Quality elements. I'm curious if others agree or have learned to count these as such, and if so, can you cite a source?
Thank you!
Recently she counted "palpitations" and "infection" as Quality elements. I'm curious if others agree or have learned to count these as such, and if so, can you cite a source?
Thank you!